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Name
Title
Please select
Mr.
Ms.
Hon.
Have you volunteered with us before?
Yes
No
Occupation
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Please select
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Why are you interested in this position?
Please outline your skills and qualifications relative to the role
Been charged with or convicted of an offence under the Criminal Code of Canada?
Yes
No
Been charged with or convicted of an offence under any other Federal statutes or regulations, including the Income Tax Act, the Controlled Drugs and Substances Act or others?
Yes
No
Been the defendant of any civil action in which allegations of fraud, theft or defamation were made against you?
Yes
No
Have any outstanding charges against you, including civil action?
Yes
No
Been charged with or convicted of any offence under any Provincial statutes or regulations?
Yes
No
Been cited with or disciplined, censured, suspended or disqualified by any professional association or body?
Yes
No
Had any improper dealings with government (e.g. improper solicitation of contracts, improper lobbying or representations)?
Yes
No
Been involved in any issue or controversy that has gone, or is likely to go, to litigation or public review?
Yes
No
Made an assignment or lodged a proposal under the Bankruptcy and Insolvency Act?
Yes
No
Been discharged, suspended or asked to resign from any employment?
Yes
No
If yes, please describe
Are you aware of any circumstances that may place you in a real, perceived, or potential conflict of interest with respect to your duties as a committee member?
Yes
No
If yes, please describe
Have you or any organization or group that you are associated with promoted or encouraged hatred against people or persons on the basis of ethnicity, language, colour, religion, culture, gender or sexual orientation?
Yes
No
If yes, please describe
Generally, are you aware of any facts or matters which, if publicly disclosed, could cause Engineers and Geoscientists BC embarrassment or hinder your performance of your duties as a committee member
Yes
No
If yes, please describe
Disclose any issues that may be of public interest in the event you are elected to serve
Describe any issues
Are you currently involved in lobbying activity
Yes
No
If yes, please describe
Confidentiality Acknowledgement
Engineers and Geoscientists BC collects, uses and retains the information on this form in accordance with the Freedom of Information and Protection of Privacy Act (RSBC 1996 Ch.165). The information is used for the purpose of evaluating candidates for an Engineers and Geoscientists BC position
Authorization Acknowledgement
Successful criminal record checks, confirmation of education credentials and professional references may be a required component of our volunteer selection process
Conflict of Interest Acknowledgement
I understand I must promptly inform Engineers and Geoscientists BC if there are significant changes to any of the above responses
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